**8. Operative treatment**

Operative treatment of Dupuytren's disease is offered in patient with contractures of >30° at the MCP joint and any functionally bothersome PIP contracture. The goal of surgical treatment is to return full extension of the involved digits via various surgical techniques involving either incising or excising the diseased fascia. Dupuytren originally described an open palmar fasciotomy technique in 1831 and this was later popularized in 1964 by McCash et al. as the open-palm technique [6, 66]. The open-palm technique involved a transverse incision across the distal palmar crease followed by incising any Dupuytren cords. Multiple surgical methods have since been described and include open fasciotomy, segmental fasciectomy, limited fasciectomy, and dermofasciectomy. These techniques range from being minimally invasive to radical excision of the diseased tissue. It is important to consider the severity of contractures, extent of correction, and risk factors for recurrence in addition to protecting soft tissues when choosing the optimal surgical treatment. Surgery is ultimately an elective form of treatment and should prompt a conversation with patients regarding the risk and benefits of surgery as well as their functional goals.

#### **8.1. Soft tissues**

Proper handling of soft tissue is a key principle of surgical treatment of Dupuytren's contractures. Adequate exposure of the cord must be balanced with protecting the neurovascular bundles, providing adequate wound coverage, limiting the risk of skin necrosis, and avoiding secondary contractures from longitudinal scarring. Multiple skin incisions have been described to address these issues and include: transverse incisions in the palm and digit, a Bruner incision, a Bruner incision with V-Y advancement flaps, curved incisions, and a longitudinal incision closed with z-plasties (**Figure 3**). Midline incisions provide the benefit of potentially avoiding the neurovascular bundles, however, Dupuytren's disease distorts regular anatomy and can tether the cord toward the midline. Curved or zig-zag incisions help avoid secondary contractures from longitudinal scars. Despite the many variations in incisions, the Bruner incision seems to be the most commonly used.

Skin closure is another important aspect of treating Dupuytren's disease. The open-palm technique described by McCash left the skin incisions open to decrease hematoma formation and allowed for secondary healing with good results [66]. Today, most incisions are closed primarily, however, increased skin tension after closure has been correlated with elevated recurrence rate (**Figure 4**). Citron and Hearnden randomized patients undergoing fasciotomies and reported a 50% recurrence rate in the group with transverse incisions closed primarily compared with a 15% rate in patients with longitudinal incisions with a z-plasty closure [67]. Another study compared Bruner's incision with direct closure to a longitudinal incision with a z-plasty closure for fasciectomy and reported no difference between the two methods [68]. Special attention should be given to skin tension during closure and a transpositional flap such as a z-plasty should be utilized if needed.

#### **8.2. Open fasciotomy**

Open fasciotomy includes a variety of surgical techniques for treating Dupuytren's contractures by incising the contracted cord without removing the diseased fascia. Many of the modern fasciotomy techniques are modifications of the methods originally described by Dupuytren and

> McCash et al. [6, 66]. Various types of incisions may be utilized to access the cord, but once the cord is visualized and incised, the digit is extended until straight. In some cases, additional incisions may be required at different levels along the cord in order to fully extend the digit. Unlike PNF, an open fasciotomy procedure provides the benefit of direct visualization to protect neurovascular structures and can often be accomplished through small incisions. In addition, it minimizes the potential morbidity sometimes seen in other techniques which excise the diseased fascia. Still, excision techniques are often preferred over an open fasciotomy for their ability to remove the diseased fascia which may aid in preventing regrowth of the cord and recurrence. This may be particularly true in patients with severe contractures. Stewart et al. retrospectively reviewed a series of patients who had open fasciotomies and reported a reoperation rate of 13.2% at 46 months with patients who initially required three level fasciotomies having worse recurrence [69]. Another study assessed 16 patients with Tubiana stage III and IV

> **Figure 4.** A post-operative image of a patient after a limited fasciectomy for a Dupuytren's contracture of the small and

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ring finger. The Brunner's incision was closed primarily with nylon sutures.

contractures and reported a higher recurrence rate of 37.5% at 5–8 year follow-up [70].

Fasciectomy is the most common surgical treatment for Dupuytren's contractures. The technique is based on the concept that the remaining diseased fascia may proliferate and lead to recurrence. Multiple methods of fasciectomies have been described and range from a segmental fasciectomy, where a portion of the fascial cord is removed, to a radical fasciectomy where skin and diseased fascia are excised. A segmental fasciectomy is usually completed through small incisions where segments of the cord are excised until the finger straightens. No attempt

**8.3. Fasciectomy**

**Figure 3.** The figure outlines types of incisions and closures options for treating Dupuytren's disease. Thumb: longitudinal incision with z-plasty closure. Index finger: Brunner incision. Middle finger: curvilinear incision. Index finger: V-Y incision. Small finger: transverse incisions utilized in the McCash open palm technique.

**Figure 4.** A post-operative image of a patient after a limited fasciectomy for a Dupuytren's contracture of the small and ring finger. The Brunner's incision was closed primarily with nylon sutures.

McCash et al. [6, 66]. Various types of incisions may be utilized to access the cord, but once the cord is visualized and incised, the digit is extended until straight. In some cases, additional incisions may be required at different levels along the cord in order to fully extend the digit. Unlike PNF, an open fasciotomy procedure provides the benefit of direct visualization to protect neurovascular structures and can often be accomplished through small incisions. In addition, it minimizes the potential morbidity sometimes seen in other techniques which excise the diseased fascia. Still, excision techniques are often preferred over an open fasciotomy for their ability to remove the diseased fascia which may aid in preventing regrowth of the cord and recurrence. This may be particularly true in patients with severe contractures. Stewart et al. retrospectively reviewed a series of patients who had open fasciotomies and reported a reoperation rate of 13.2% at 46 months with patients who initially required three level fasciotomies having worse recurrence [69]. Another study assessed 16 patients with Tubiana stage III and IV contractures and reported a higher recurrence rate of 37.5% at 5–8 year follow-up [70].

#### **8.3. Fasciectomy**

Bruner incision, a Bruner incision with V-Y advancement flaps, curved incisions, and a longitudinal incision closed with z-plasties (**Figure 3**). Midline incisions provide the benefit of potentially avoiding the neurovascular bundles, however, Dupuytren's disease distorts regular anatomy and can tether the cord toward the midline. Curved or zig-zag incisions help avoid secondary contractures from longitudinal scars. Despite the many variations in incisions, the

Skin closure is another important aspect of treating Dupuytren's disease. The open-palm technique described by McCash left the skin incisions open to decrease hematoma formation and allowed for secondary healing with good results [66]. Today, most incisions are closed primarily, however, increased skin tension after closure has been correlated with elevated recurrence rate (**Figure 4**). Citron and Hearnden randomized patients undergoing fasciotomies and reported a 50% recurrence rate in the group with transverse incisions closed primarily compared with a 15% rate in patients with longitudinal incisions with a z-plasty closure [67]. Another study compared Bruner's incision with direct closure to a longitudinal incision with a z-plasty closure for fasciectomy and reported no difference between the two methods [68]. Special attention should be given to skin tension during closure and a transpositional

Open fasciotomy includes a variety of surgical techniques for treating Dupuytren's contractures by incising the contracted cord without removing the diseased fascia. Many of the modern fasciotomy techniques are modifications of the methods originally described by Dupuytren and

**Figure 3.** The figure outlines types of incisions and closures options for treating Dupuytren's disease. Thumb: longitudinal incision with z-plasty closure. Index finger: Brunner incision. Middle finger: curvilinear incision. Index finger: V-Y incision.

Small finger: transverse incisions utilized in the McCash open palm technique.

Bruner incision seems to be the most commonly used.

flap such as a z-plasty should be utilized if needed.

**8.2. Open fasciotomy**

70 Essentials of Hand Surgery

Fasciectomy is the most common surgical treatment for Dupuytren's contractures. The technique is based on the concept that the remaining diseased fascia may proliferate and lead to recurrence. Multiple methods of fasciectomies have been described and range from a segmental fasciectomy, where a portion of the fascial cord is removed, to a radical fasciectomy where skin and diseased fascia are excised. A segmental fasciectomy is usually completed through small incisions where segments of the cord are excised until the finger straightens. No attempt is made to removal the complete cord. The most widely used technique is a limited fasciectomy and is considered the gold standard in the operative treatment of Dupuytren's contractures (**Figure 5**). The technique involves carefully exposing the diseased fascia from its proximal to distal end and excising it from the surrounding soft tissue (**Figure 6**). It differs from a radical fasciectomy by removing only the diseased fascia and leaving normal fascia, subcutaneous tissue, and the dermis intact. Radical fasciectomy advocated by McIndie and Beare involved extensive removal of nearby tissue and skin and required a skin graft [71]. However, the technique largely fell out of favor due to a higher complication rate without a reduction in recurrence. A dermatofasciectomy is similar to a limited fasciectomy but involves excising the overlying skin and often requires a skin graft for coverage. Advocates of this technique report disease-forming cells may be left in the overlying soft tissue leading to recurrence and selectively use it in patients at higher risk for recurrence. Despite the variety of techniques, fasciectomies require meticulous dissection to avoid injuring neurovascular bundles which may be displaced by a contracted cord. In addition, maintaining hemostasis is important to prevent hematoma formation which can compromise healing. Overall, fasciectomies offer the benefit of removing more diseased fascia but are accompanied by increased morbidity related to a more extensive exposure.

#### **8.4. Post-operative protocol**

Most surgeons utilize some form of rehabilitation to prevent further contractures and maintain ROM. After surgery, patients are typically immobilized in an extension-based splint for 2–3 days. Wounds are closely monitored following surgery to ensure adequate healing and to identify any barriers to healing such as infection, hematoma, or skin necrosis. Patients are often referred to a hand therapist within the first week of surgery for wound care, scar management, range of motion exercises, and splinting techniques to prevent contracture formation. A variety of splinting protocols and types of orthoses have been described. In general, protocols may involve static or dynamic splinting and be utilized at different periods of the day. Despite the widespread use of post-operative splinting, studies have found no strong evidence they are effecting in preventing loss of extension or recurrence. Collis et al. randomized patients to night

time extension orthoses and hand therapy or hand therapy alone and reported no differences between the two groups in terms of active ROM or hand function [72]. A similar study found night time splinting offered no benefit in terms of ROM and function at 1 year after surgery and recommended splinting should only be utilized when extension deficits occur [73]. Overall, less invasive procedures allow for earlier rehabilitation and a shorter recovery period. In addition, wound healing often dictates how fast a patient can progress following surgery. A segmental aponeuroectomy may involve a 2–3 week recovery period whereas a fasciectomy may involve

**Figure 6.** An intraoperative image of a patient undergoing a limited fasciectomy for a Dupuytren's contracture of the ring finger. (A) A Brunner's incision was utilized to exposed the disease tissue. The longitudinal band of the palmar aponeurosis is being elevated. (B) The diseased fascia was meticulously elevated from proximal to distal. (C) The diseased

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Overall, surgery is an effective method of treating Dupuytren's contractures and improving patients' hand function. In a survey of over 1100 patients who underwent surgical treatment 75% reported almost full or full correction of their contracture [74]. Zyluk et al. reported patients had significantly improved hand function as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after undergoing a subtotal fasciectomy [75]. In

a much longer recovery period.

fascia after removal from the digit.

**9. Patient outcomes**

**Figure 5.** An intraoperative image of a patient undergoing a limited fasciectomy for a Dupuytren's contracture of the small finger. A Brunner's incision was utilized to exposed the disease tissue. The Dupuytren's cord is being elevated by the forceps.

**Figure 6.** An intraoperative image of a patient undergoing a limited fasciectomy for a Dupuytren's contracture of the ring finger. (A) A Brunner's incision was utilized to exposed the disease tissue. The longitudinal band of the palmar aponeurosis is being elevated. (B) The diseased fascia was meticulously elevated from proximal to distal. (C) The diseased fascia after removal from the digit.

time extension orthoses and hand therapy or hand therapy alone and reported no differences between the two groups in terms of active ROM or hand function [72]. A similar study found night time splinting offered no benefit in terms of ROM and function at 1 year after surgery and recommended splinting should only be utilized when extension deficits occur [73]. Overall, less invasive procedures allow for earlier rehabilitation and a shorter recovery period. In addition, wound healing often dictates how fast a patient can progress following surgery. A segmental aponeuroectomy may involve a 2–3 week recovery period whereas a fasciectomy may involve a much longer recovery period.

### **9. Patient outcomes**

is made to removal the complete cord. The most widely used technique is a limited fasciectomy and is considered the gold standard in the operative treatment of Dupuytren's contractures (**Figure 5**). The technique involves carefully exposing the diseased fascia from its proximal to distal end and excising it from the surrounding soft tissue (**Figure 6**). It differs from a radical fasciectomy by removing only the diseased fascia and leaving normal fascia, subcutaneous tissue, and the dermis intact. Radical fasciectomy advocated by McIndie and Beare involved extensive removal of nearby tissue and skin and required a skin graft [71]. However, the technique largely fell out of favor due to a higher complication rate without a reduction in recurrence. A dermatofasciectomy is similar to a limited fasciectomy but involves excising the overlying skin and often requires a skin graft for coverage. Advocates of this technique report disease-forming cells may be left in the overlying soft tissue leading to recurrence and selectively use it in patients at higher risk for recurrence. Despite the variety of techniques, fasciectomies require meticulous dissection to avoid injuring neurovascular bundles which may be displaced by a contracted cord. In addition, maintaining hemostasis is important to prevent hematoma formation which can compromise healing. Overall, fasciectomies offer the benefit of removing more diseased fascia but are accompanied by increased morbidity related

Most surgeons utilize some form of rehabilitation to prevent further contractures and maintain ROM. After surgery, patients are typically immobilized in an extension-based splint for 2–3 days. Wounds are closely monitored following surgery to ensure adequate healing and to identify any barriers to healing such as infection, hematoma, or skin necrosis. Patients are often referred to a hand therapist within the first week of surgery for wound care, scar management, range of motion exercises, and splinting techniques to prevent contracture formation. A variety of splinting protocols and types of orthoses have been described. In general, protocols may involve static or dynamic splinting and be utilized at different periods of the day. Despite the widespread use of post-operative splinting, studies have found no strong evidence they are effecting in preventing loss of extension or recurrence. Collis et al. randomized patients to night

**Figure 5.** An intraoperative image of a patient undergoing a limited fasciectomy for a Dupuytren's contracture of the small finger. A Brunner's incision was utilized to exposed the disease tissue. The Dupuytren's cord is being elevated by the forceps.

to a more extensive exposure.

72 Essentials of Hand Surgery

**8.4. Post-operative protocol**

Overall, surgery is an effective method of treating Dupuytren's contractures and improving patients' hand function. In a survey of over 1100 patients who underwent surgical treatment 75% reported almost full or full correction of their contracture [74]. Zyluk et al. reported patients had significantly improved hand function as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after undergoing a subtotal fasciectomy [75]. In addition, patient's experienced a significant improvement in the total loss of extension from an average of 80 to 10°. Another study prospectively evaluated 90 patients undergoing a fasciectomy for a 60-degree or more deficit in total active extension and reported 81% patient satisfaction with function, 87% reaching functional ROM, and significantly improved DASH scores at 1 year follow up [76].

diathesis is a term coined by Hueston describing certain characteristics related to severe disease and increased recurrence [83]. Hindocha modified the criteria to include the following features within a Northern European population: male sex, <50 years old, bilateral disease, affected parent or sibling, and presence of Garrod's nodes and reported patients with all 5 features had a recurrence rate of 71% [84]. However, other studies have failed to demonstrate a significant correlation with recurrence among all 5 diathesis criteria. Van Rijssen reported only older age was found to delay recurrence after PNF and limited fasciectomy [62]. PIP joint contractures have an elevated recurrence rate after surgery compared to the MCP joint. Donaldson et al. reported 34.2% of fully corrected PIP joints experienced at least some loss of correction compared with 12.2% of MCP joints [80]. Patients with severe preoperative PIP contractures greater than 60°, incomplete correction, and poor post-operative compliance had significantly

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Surgical management of recurrent disease is challenging as anatomic landmarks and tissue plans become difficult to distinguish. There is currently limited data regarding the preferred surgical treatment. Roush and Stern compared dermatofasciectomy with a skin graft, interphalangeal joint arthrodesis, and fasciectomy with local flaps among 19 patients with recurrence after a prior surgery [85]. The fasciectomy cohort was the only group to significantly maintain total active motion at final follow-up, but all three groups had similar patient reported outcomes. It is important patients are aware of the risk of recurrence prior to their initial surgery and personal factors which may increase their likelihood of

Despite good outcomes after surgical treatment of Dupuytren's contractures surgery is not without complications. A 20 year systematic review of complications by Denkler et al. reported an average major complication risk of 15% with complication rates ranging from 3.6 to 39.1% [86]. Specific complications after limited fasciectomy included the following: wound healing problems, 22.9%; flare reaction, 9.9%; complex region pain syndrome, 5.5%; nerve injury, 3.4%; infection, 2.4%; hematoma, 2.1%; and digit artery injury, 2%. Severe complications include tendon rupture or loss of the digit but are extremely rare. Patients with severe flexion contractures are more at risk of experiencing a complication [87]. Smoking and diabetes, however, has not been identified as an increased risk factor for wound healing problems after surgery [88]. Patients undergoing revision surgery for recurrence are most at risk for complications, especially neurovascular injuries due to scar tissue and loss of anatomic landmarks. Neurovascular injuries have been reported as high as 10 times more common in

Dupuytren's disease is a unique fibroproliferative disorder of palmar fascia likely resulting from a complex interplay of genetic and environmental factors. Despite extensive research,

worse recurrence [78].

recurrence.

**11. Complications**

revision surgeries for recurrence [86].

**12. Conclusion**

Further analysis of surgical treatment has lead authors to identify certain characteristic associated with better outcomes. Patients with MCP contractures are more likely to achieve full intra-operative correction (Donaldson). However, correction of PIP contractures has a stronger correlation to improved hand function when compared with correction of the MCP joint [77]. Surgical treatment has focused on PIP contractures to maximize intra-operative correction and improve functional outcomes. Surgeons have tried releasing the PIP capsule with a fasciectomy to improve PIP correction, but there is no strong data to support whether it is effective [78]. Zyluk et al. reported younger patients had a significantly greater functional improvement after surgery as measured by the DASH score [75]. Studies have also cited the extent of preoperative deformity, incomplete correction, and multiple involved digits as factors affecting post-operative functional outcomes [75, 78–80].

Despite multiple studies reporting good outcomes after surgery, there are limited randomized studies comparing outcomes after different operative techniques. Ullah et al. found no difference in ROM or recurrence in 79 patients randomized to either direct closure with z-plasty or firebreak skin grafting after a fasciectomy, however, patients with skin grafting had an increased incidence of hypoesthesia [81]. Van Rijssen et al. randomized patients to percutaneous needle fasciotomy and limited fasciectomy and reported the PNF group was significantly higher recurrence rate (76.8 vs. 20.9%, p < 0.001) and lower VAS satisfaction scores (6.2 vs. 8.3, p < 0.001) [62]. Further prospective, randomized studies reporting functional outcomes, complications, and recurrence rates are necessary to recommend any surgical procedure.

### **10. Recurrence**

Recurrence of a Dupuytren's contracture is a common event even after successful initial treatment. A systematic review analyzed 51 studies and reported recurrence rates ranged from 0 to 71% [82]. Furthermore, recurrence rates are difficult to assess as there is considerable variation in the criteria used to define recurrence. Some authors report the presence of any diseased tissue after treatment while others include only contractures necessitating re-operation. More recently, studies have tended to define recurrence as a 20–30° loss of extension in a successfully treated digit. A recent randomized study defined recurrence as a 20° reduction of total passive extension in a successfully treated digit and reported a 20.9% 5-year recurrence rate after limited fasciectomy [62].

Multiple studies have focused on identifying factors which may predispose patients to recurrence. The dramatic variability of recurrence rates may be due to the heterogeneity of the presentation of Dupuytren's itself, as many patients may have more aggressive biology associated with "Dupuytren's diathesis", whereas others may have more mild disease. Dupuytren diathesis is a term coined by Hueston describing certain characteristics related to severe disease and increased recurrence [83]. Hindocha modified the criteria to include the following features within a Northern European population: male sex, <50 years old, bilateral disease, affected parent or sibling, and presence of Garrod's nodes and reported patients with all 5 features had a recurrence rate of 71% [84]. However, other studies have failed to demonstrate a significant correlation with recurrence among all 5 diathesis criteria. Van Rijssen reported only older age was found to delay recurrence after PNF and limited fasciectomy [62]. PIP joint contractures have an elevated recurrence rate after surgery compared to the MCP joint. Donaldson et al. reported 34.2% of fully corrected PIP joints experienced at least some loss of correction compared with 12.2% of MCP joints [80]. Patients with severe preoperative PIP contractures greater than 60°, incomplete correction, and poor post-operative compliance had significantly worse recurrence [78].

Surgical management of recurrent disease is challenging as anatomic landmarks and tissue plans become difficult to distinguish. There is currently limited data regarding the preferred surgical treatment. Roush and Stern compared dermatofasciectomy with a skin graft, interphalangeal joint arthrodesis, and fasciectomy with local flaps among 19 patients with recurrence after a prior surgery [85]. The fasciectomy cohort was the only group to significantly maintain total active motion at final follow-up, but all three groups had similar patient reported outcomes. It is important patients are aware of the risk of recurrence prior to their initial surgery and personal factors which may increase their likelihood of recurrence.
